Cannamedical Qualifying Quiz

1

Clinic Code

2

Referring Clinic

3

Name* This field is required.As it appears on Your Medicare Card

First Name

Last Name

4

Are you older than 21 Years?* This field is required.

YESNO

5

Unfortunately we do not currently allow patients under 21 to book online for their initial consultation.

example@example.com

6

Do you have a chronic medical condition or conditions that has persisted for longer than 3 Months?* This field is required.Some examples may include Chronic pain, Cancer & Cancer Pain, Multiple Sclerosis, Epilepsy, Chemotherapy-induced nausea and vomiting (CINV), Parkinson’s Disease, Glaucoma, PTSD, Anxiety, Sleep disorders, Neuropathic pain, Rheumatoid Arthritis, Fibromyalgia.

YESNO

7

Have you tried other treatments for your medical condition(s)?* This field is required.It's not necessary to have tried and failed all other treatment options. However, you must have attempted some initial first line treatments, such as medications prescribed by a healthcare professional.

YESNO

8

Based on your responses you may qualify for medical cannabis treatment. The next step would be to schedule an appointment with one of our Telehealth professionals. Please enter your email and press submit and you will be redirected to our bookings page.* This field is required.

example@example.com

9

The Therapeutic Goods Administration has set specific criteria which limit access to medical cannabis for some patients. The primary requirement is that the patient must have a chronic medical condition and have failed to find relief through traditional therapies or medications. If you would like to discuss your medical condition and the possibility of using medical cannabis, please provide your email and phone number, and our expert team will reach out to you.* This field is required.

example@example.com

10

Test Result